The large dataset sizes of medical images, an important component of the medical record generated during a patient's hospital stay or clinic visit, unfortunately represent a difficult-to-manage data source. In attempting to consolidate medical images with conventional textual medical record data in the Medical information System (MIS), the NIH Clinical Center (CC) is pursuing the goal of creating a comprehensive electronic medical record. Toward this end, DCRT and the CC are collaborating in a series of demonstration projects exploring image integration into electronic medical records. Images of interest range in size from 16 Kbytes (diagnostic electrocardiograms) to 256 Kbytes (tomographic scans) to 4 Mbytes (conventional film Xrays). Standard 12-lead electrocardiograms (ECG) are automatically acquired, interpreted, and stored in digital form on an ECG Data Management System in the CC. A remote ECG workstation is being developed as a serial RS-232 gateway to transfer ECG waveforms and their related diagnoses from this system to the MIS. Since ECG waveforms are essentially binary images in which the black pixel content is only ca. 0.1%, ECG waveform data are more efficiently stored and transmitted as time-ordered lists of 10-bit ECG amplitudes rather than as 2.75K X 3K pixel images. Chest X-rays routinely obtained within the Diagnostic Radiology Department are appropriate for integration into the MIS as well as for transmission to the relevant outpatient clinic. A recently acquired Vision Ten RITA! system, containing a gray-scale sheet film digitizer, and two RITA!- compatible image display systems, are integral parts of the image gateway. Communication of medical images between the Radiology Department Film Library and remote sites is now possible over the CC fiber optic network. The NHLBI Cardiac Surgical Clinic was the first outpatient clinic to routinely use chest films transmitted over this Ethernet pathway. Future plans include the connection of two CT scanners to this system via ACR-NEMA communication links to dedicated image servers added to the teleradiology network.